What is the management for a 65-year-old lady with right hypochondrial pain, no stones in the common bile duct (CBD), and laparoscopic exploration showing a dilated gallbladder (GB) with peritoneal nodules?

Management of Suspected Gallbladder Malignancy with Peritoneal Nodules

Extended cholecystectomy (option D) is the recommended management for this 65-year-old lady with right hypochondrial pain, dilated gallbladder, and peritoneal nodules found during laparoscopic exploration. 1

Rationale for Extended Cholecystectomy

The clinical presentation strongly suggests gallbladder malignancy with peritoneal metastases, which requires aggressive surgical management:

• The finding of peritoneal nodules with a dilated gallbladder in the absence of CBD stones is highly suspicious for malignancy
• Extended cholecystectomy provides the best oncological clearance and improved survival outcomes 1
• This approach involves:
  • Removal of the gallbladder
  • Resection of a wedge of adjacent liver tissue (segments IVb and V)
  • Regional lymph node dissection
  • Sampling or removal of peritoneal nodules

Why Other Options Are Suboptimal

• En bloc GB resection (option A): While this involves removing the gallbladder with surrounding tissues, it doesn't specifically address the need for liver segment resection and lymph node dissection required in suspected malignancy
• Cholecystectomy (option B): Simple cholecystectomy is inadequate for suspected malignancy as it fails to provide adequate oncological clearance 1
• Palliative Cholecystectomy (option C): While palliative procedures may be considered in some advanced cases, the American College of Surgeons recommends extended cholecystectomy as the best oncological approach even when peritoneal nodules are present 1

Surgical Approach Considerations

1. Intraoperative assessment is crucial:

   • Frozen section should be performed to confirm malignancy
   • Biopsy of peritoneal nodules for histopathological examination 1

2. Patient-specific factors:

   • Age alone (65 years) should not preclude aggressive surgical management
   • Frailty assessment is more important than chronological age in determining surgical risk 1

3. Surgical expertise:

   • Extended cholecystectomy requires specialized surgical expertise
   • Referral to a hepatobiliary center may be necessary if specialized expertise is not available locally 1

Post-operative Considerations

• Close monitoring for complications
• Multidisciplinary approach for potential adjuvant therapy based on final pathology
• Follow-up imaging to monitor for recurrence

While palliative procedures may be considered in patients with very limited life expectancy 2, the finding of peritoneal nodules without confirmation of widespread metastatic disease warrants the more aggressive extended cholecystectomy approach to provide the best chance for disease control and improved quality of life 1.